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Use of an Anti-Infective Medication Assignment 12

Use of an Anti-Infective Medication Assignment 12

Use of an Anti-Infective Medication Assignment 12

Use of an Anti-Infective Medication Review Process at Hospital Discharge to Identify Medication Errors and Optimize Therapy

Christy P. Su, PharmD, BCPS 1 , Levita Hidayat, PharmD

2 ,

Shafiqur Rahman, MD 3 , and Veena Venugopalan, PharmD, BCPS, AQ-ID


Abstract Background: Medication reconciliation is a major patient safety concern, and the impact of a structured process to evaluate anti- infective agents at hospital discharge warrants further review. Objective: The aim of this study was to (1) describe a structured, multidisciplinary approach to review anti-infectives at discharge and (2) measure the impact of a stewardship-initiated anti- microbial review process in identifying and preventing anti-infective-related medication errors (MEs) at discharge. Methods: A prospective study to evaluate adult patients discharged on anti-infectives was conducted from October 2013 to May 2014. The antimicrobial stewardship program (ASP) classified interventions on anti-infective regimens into predefined ME categories. Results: Forty-five patients who were discharged on 59 anti-infective prescriptions were included in the study. The most common indications for anti-infective regimens at discharge were pneumonia (22%, n ¼ 10), bacteremia (18%, n ¼ 8), and skin and soft tissue infections (16%, n ¼ 7). An ME was identified in 42% (n ¼ 19/45) of anti-infective regimens. Seventy percentage of ASP team recommendations were accepted which resulted in an avoidance of MEs in 68% (n ¼ 13/19) of patients with an ME prior to discharge. Conclusion: This study describes the outcomes of a stewardship-initiated review process in preventing MEs at discharge. Developing a systematic process for a multidisciplinary ASP team to review all anti-infectives can be a valuable tool in preventing MEs at hospital discharge.


Keywords antimicrobial stewardship, transitions of care, hospital discharge, medication errors, medication reconciliation


Transition of care from hospital to community can be a high-

risk period for medication errors (MEs). 1

The National

Coordinating Council for Medication Error Reporting and

Prevention (NCCMERP) defines ME as any preventable event

that may cause or lead to inappropriate medication use or

patient harm, while the medication is in the control of the

health-care provider, patient, or consumer. 2

Forster and col-

leagues noted that 66% of adverse events (AEs) occurring in patients following hospital discharge were medication related

and could be prevented in 27% of cases. Furthermore, anti- infective agents were identified as one of the most common

medication classes associated with adverse drug events with a

reported rate of 5.1 AE per 100 prescriptions. 3,4 Use of an Anti-Infective Medication Assignment 12

ME prevention is a major patient safety concern which has

received national attention. 5

Many patients who receive anti-

microbials in hospitals are also discharged on antimicrobial

therapy, to complete the treatment course at home, in long-

term acute care centers, skilled nursing facilities, outpatient

infusion centers, or dialysis centers. 6,7

In the absence of anti-

microbial stewardship oversight at these transitions of care

points, patients may be discharged from hospitals on

inappropriate therapy. This presents a unique opportunity for

antimicrobial stewardship programs (ASP) to be involved in

the discharge process. We conducted a pilot study at The

Brooklyn Hospital Center (TBHC), a 416-bed community

teaching facility in Brooklyn, New York. The objectives of this

study were to (1) describe a structured, multidisciplinary

approach to review anti-infective prescriptions at discharge and

(2) measure the impact of a stewardship-initiated anti-infective

review process in identifying and preventing anti-infective-

related MEs at discharge. The experience gained from this

1 Department of Pharmacy, Memorial Hermann Greater Heights Hospital,

Houston, TX, USA 2 Global Health Science, The Medicines Company, Parsipanny, NJ, USA 3 Division of Infectious Diseases, The Brooklyn Hospital Center, Brooklyn, NY,

USA 4 Department of Pharmacotherapy and Translational Research, College of

Pharmacy, University of Florida, Gainesville, FL, USA

Corresponding Author:

Christy P. Su, Department of Pharmacy, Memorial Hermann Greater Heights

Hospital, 1635 North Loop West, Houston, TX 77008, USA.


Journal of Pharmacy Practice 2019, Vol. 32(5) 488-492 ª The Author(s) 2018 Article reuse guidelines: DOI: 10.1177/0897190018761411
study is critical in identifying institutional resources needed to

implement an anti-infective review process and sustain it to

produce desired outcomes. Use of an Anti-Infective Medication Assignment 12


A single-center prospective study was conducted at TBHC

from October 2013 to May 2014. TBHC has a centralized

pharmacy model. Pharmacists in the central inpatient pharmacy

provide distributional services and primarily serve in a drug

dispensing role. There are also clinical pharmacy specialists

integrated into the patient care teams within the medical inten-

sive care, family medicine, and pediatrics units. These pharma-

cists perform a combination of clinical and distributional

activities. At the time of this study, the pharmacy department

operated with 11 clinical pharmacy specialists which included

coverage for inpatient and outpatient clinical services. The

ASP was established in 2004 and comprised of infectious dis-

eases (ID) physicians, ID clinical pharmacists, and a PGY-2 ID

resident. The ASP was actively involved in prospective anti-

infective review during hospitalization; however, no process

was in place for the assessment of discharge treatment.

To begin the development of a systematic process to review

anti-infective agents at discharge, one hospital service was

selected during this study period, with future plans to expand

the initiative hospital-wide. Patients greater than 18 years of age

who were discharged from the family medicine service on intra-

venous (IV) or oral anti-infective therapy were included in this

initiative. MEs were identified according to NCCMERP and

were classified into the following predefined categories by

Heintz and colleagues: safety, efficacy, or simplification. 8


interventions included those related to ordering laboratory tests,

adjusting doses due to renal dysfunction, avoiding central line

placement, avoiding unnecessary anti-infective agents, reassess-

ment of patient’s stability, or adjusting therapy due to drug

interactions. Efficacy interventions included those related to

anti-infective selection, dose, or extending the duration of ther-

apy. Simplification interventions included those related to reduc-

ing the frequency of dosing, performing IV to oral interchange,

reducing the number of anti-infective agents prescribed, or short-

ening the duration of therapy (Table 1). Each anti-infective agent

prescribed could have more than 1 type of intervention.

The stepwise process of implementing the review process is

depicted in Figure 1.  Use of an Anti-Infective Medication Assignment 12The ASP clinical pharmacist contacted the

family medicine team daily for a list of patients with an anticipated

discharge within 48 hours. The ASP team then screened these

patients for anti-infective prescriptions through electronic medi-

cal records. Patients who had a prescribed anti-infective agent

were evaluated by the ASP team for appropriateness based on

evidence-based practice guidelines. Potential interventions that

were identified were then verbally communicated and discussed

with the primary team physician. However, if a patient received an

ID consultation during hospital admission, the ID consultant

would be contacted and changes to treatment regimens were made

collaboratively with the ASP team. All recommendations were

made prior to patient discharge and the number of accepted inter-

ventions and types were quantified. Descriptive statistics were

used to present the results. This study was conducted in compli-

ance with the hospital’s institutional review board.

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